- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $166.95 / $271.29 / $352.25
| Facility | 26 | $166.95 | $271.29 | $352.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.50 / $600.00 / $2,533.01
| Professional | | $370.50 | $600.00 | $2,533.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.21 / $1,054.39 / $1,327.89
| Professional | | $362.21 | $1,054.39 | $1,327.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $480.99 / $794.87 / $1,239.02
| Professional | | $480.99 | $794.87 | $1,239.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.83 / $734.14 / $879.74
| Professional | | $391.83 | $734.14 | $879.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $115.00 / $115.00
| Professional | | $115.00 | $115.00 | $115.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $392.45 / $653.39 / $1,231.91
| Professional | | $392.45 | $653.39 | $1,231.91 |